[The gastroschisis: clinical and therapeutic considerations]. / Laparoschizisul: consideratii clinico-terapeutice.

Gastroschisis is a severe congenital malformation of the abdominal wall, with relative low incidence. The authors are analysing different therapeutic methods, in a group of 17 cases, hospitalised and operated in Department of Pediatric Surgery, Emergency Hospital of Craiova. They are underlining the importance of the ultrasound prenatal diagnosis of the malformation, close related to different therapeutic methods applied in this period of time and also are advising secondary closure of the abdominal wall, using a synthetic material (Silo-bag) for temporary coverage of the intestine developed outside the peritoneal cavity. This method helped with the decreasing of mortality in gastroschisis but with high costs of treatment.

Benign pneumatosis intestinalis coli after blunt trauma to the abdomen in a child.

This report describes a 2 1/2-year-old boy who sustained blunt abdominal trauma and had pneumatosis intestinalis in the right colon. The child was successfully managed by observation. The pneumatosis resolved spontaneously.

Acquired ileal atresia and spontaneous reconstitution of intestinal continuity in a premature infant with necrotizing enterocolitis.

An 849-g (26-week gestation) premature infant had pneumoperitoneum on the 20th day of life after having normal stools and accepting partial enteric alimentation. Percutaneous penrose drainage had to be performed on 2 consecutive days at 2 different sites (right lower quadrant, left lower quadrant), at which time she stabilized. Eleven days later, she started to pass stool, and oral feeding was begun (1 to 2 mL every 4 hours). Enteral intake could not be advanced because of repeated bouts of abdominal distension, despite having regular bowel motions. Gastrointestinal contrast radiographic investigation suggested a stricture of the ileum. At laparotomy (at age 2 months) ileal atresia with a "V"-shaped defect in the mesentery was found. Surprisingly, intestinal continuity was established via an ileoileal fistula. After resection and anastomosis, she recovered fully. Mesenteric and enteric vascular ischemia (necrotizing enterocolitis) produced acquired ileal atresia-a rare occurrence. More rare is the reestablishment of intestinal continuity by fistulization.

Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease: a new gold standard.

OBJECTIVE: To describe the surgical technique and early clinical results after a one-stage laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease. SUMMARY BACKGROUND DATA: Recent trends in surgery for Hirschsprung's disease have been toward earlier repair and fewer surgical stages. A one-stage pull-through for Hirschsprung's disease avoids the additional anesthesia, surgery, and complications of a colostomy. A laparoscopic-assisted approach diminishes surgical trauma to the peritoneal cavity. METHODS: The technique uses four small abdominal ports. The transition zone is initially identified by seromuscular biopsies obtained laparoscopically. A colon pedicle preserving the marginal artery is fashioned endoscopically. The rectal mobilization is performed transanally using an endorectal sleeve technique. The anastomosis is performed transanally 1 cm above the dentate line. This report discusses the outcome of primary laparoscopic pull-through in 80 patients performed at six pediatric surgery centers over the past 5 years. RESULTS: The age at surgery ranged from 3 days to 96 months. The average length of the surgical procedure was 2.5 hours. Almost all of the patients passed stool and flatus within 24 hours of surgery. The average time for discharge after surgery was 3.7 days. All 80 patients are currently alive and well. Most of the children are too young to evaluate for fecal continence, but 18 of the older children have been reported to be continent. CONCLUSION: Laparoscopic-assisted colon pull-through appears to reduce perioperative complications and postoperative recovery time dramatically. The technique is quickly learned and has been performed in multiple centers with consistently good results.

Progressive tumor necrosis and lethal hyperkalemia in a neonate with sacrococcygeal teratoma (SCT).

Tumor lysis syndrome is known among patients undergoing induction therapy for lymphocytic malignancies. Spontaneous tumor lysis in patients with solid tumors is distinctly rare. To our knowledge, the phenomenon of spontaneous tumor lysis has been described only once in infancy, in association with the surgical manipulation of a hepatoblastoma. This is the first report of a newborn with sacrococcygeal teratoma who experienced spontaneous tumor lysis-induced hyperkalemia. Because cardiac arrest may be among the leading causes of operative mortality in babies with sacrococcygeal teratoma, intraoperative monitoring of serum K+ should be conducted frequently.

Laparoscopic pull-through procedure for Hirschsprung's disease.

Contemporary surgical management of Hirschsprung's disease (HD) has evolved toward resection and reconstruction earlier in life. The introduction and miniaturization of laparoscopic instrumentation currently permits the application of this approach to the treatment of HD in the neonate. The authors' experience with this technique demonstrates several potential advantages over the "classical" two-stage operation.

Allantoic cyst and persistent urachal-allantoic communication: a rare umbilical anomaly.

True cysts of the umbilical cord are distinctly rare. A cyst lined by uroepithelium is described in a newborn in whom the cyst communicated freely with a patent urachal system. It is assumed that this most likely represents a remnant cyst of the allantois--an anomaly not described previously.

Advances in fetal surgery.

The use of maternal/fetal ultrasound screening has become commonplace in today's society. The principle behind fetal surgery evolves around the potential of correction or interruption of various abnormal processes that may bring about fetal demise or can become life-threatening to the newborn. This article reviews the progressive technical improvements and advances in fetal surgery.

Advances in neonatal surgery.

Neonatal surgery has reached a high degree of sophistication. We are now entering a new era of widespread screening of the unborn by means of ultrasound, with planned intrauterine, intrapartum, and immediate postpartum interventions. Many pediatric surgical centers are now focusing their investigative efforts on elucidating the cellular, molecular, and biochemical response to disease and therapeutic agents. The author presents the topic of neonatal surgery to some of the newer applications, techniques, and approaches.

Accidental anorectal impalement in children.

Forceful noniatrogenic injuries of the anorectum in children are rare. The majority are caused by falls at play or by a child molester. Local tissue and sphincteric destruction and, in addition, peritoneal penetration with associated organ involvement, hallmark these potentially life-threatening injuries. The configuration of the offending object, the force and direction of its penetration, and the resting point of its tip will dictate the nature and extent of the injuries. These in turn will suggest the therapeutic approaches. Classification of anorectal impalement injuries based on the site of penetration (anal vs perineal) and its final target (intra- vs extraperitoneal), will provide a rational schema of treatment.

Congenital anorectal teratoma: report of a case.

This is the first reported case of congenital anorectal teratoma. Total disconnection from the coccyx and mucomembranous covering distinguish this tumor from the more common sacrococcygeal teratoma. Complete surgical excision is important to avoid recurrence or malignant transformation.

Congenital hernia of the cord and associated patent omphalomesenteric duct: a frequent neonatal problem?

Six neonates with hernia of the umbilical cord (HUC) and associated patent omphalomesenteric duct (POMD) were treated in our hospital in a 10-year period and are reported in order to emphasize the potential hazard of clamping the bowel at the time of the handling of the umbilicus. Any unusual thickening of the base of the cord along with even the most minute fistula opening to its side should alert the physician to the existence of these combined anomalies. The cord in such patients must be clamped a safe distance away and early pediatric surgical consultation must be contemplated. Obstetricians, pediatricians, and nurses who customarily clamp, manipulate, or shorten the cord in the delivery room or upon arrival in the nursery should be aware of this not-so-rare combination of anomalies of the umbilical cord and the intestines.

Extramediastinal bronchogenic cysts in children.

Three children with subcutaneous masses were found to have extramediastinal bronchogenic cysts. The suprasternal area is by far the most common location of this highly unusual embryonic rest cyst. In one of our patients a cyst was located in the scapular region, which is a particularly rare site. To date only 41 subcutaneous bronchogenic cysts have been reported. Preoperative diagnosis is difficult, although the presence of clear mucoid material within the cyst may suggest the diagnosis. The histologic presence of ciliated, pseudostratified, columnar or cuboidal epithelium, mucus-secreting glands, smooth muscles, and occasional cartilage establishes the diagnosis.

Posterior cervical torticollis caused by birth trauma.

A case of posterior cervical torticollis is described. This is an unusual manifestation of this common condition. In addition, evidence is given to support birth trauma as the etiologic factor in this problem.

Nonsurgical therapy of splenic rupture in a hemophiliac.

A boy with known hemophilia A sustained severe blunt abdominal trauma that caused major splenic rupture and hypovolemia. The administration of blood and aggressive clotting factor replacement therapy stabilized his course and he was successfully managed without resorting to operation.

The surgical approach for reconstruction of the sternal and epigastric defects in children with Cantrell's deformity.

Children with Cantrell's deformity manifest a midline defect of the lower sternum and epigastrium. A surgical technique is described that uses the lowermost sternocostal cartilages in reconstructing the defected sternum and simultaneously reapproximating the rectus abdominis muscles in the middle line for repair of the epigastric defect. Solid cardiac protection and superior cosmetic results were obtained without the use of foreign prosthetic material.

Elevated liver transaminase levels in children with blunt abdominal trauma: a predictor of liver injury.

The medical records of 43 hemodynamically stable children with elevated serum transaminase levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) who underwent abdominal computed tomographic (CT) scan for blunt abdominal trauma were reviewed. Nineteen patients (44.2%) had AST levels greater than 450 IU/L and ALT levels greater than 250 IU/L, and 17 of these 19 patients had hepatic injury identified on abdominal CT scan. Of the 43 patients, 25 (58.1%) had AST and ALT levels of less than 450 IU/L and 250 IU/L, respectively, and none of these patients had evidence of hepatic injury on CT scan. Elevated serum transaminase levels (AST greater than 450 IU/L and ALT greater than 250 IU/L) identified all of the patients with hepatic injury visible on abdominal CT scan. The sensitivity and specificity of elevated serum transaminase levels were 100% and 92.3%, respectively, for predicting hepatic injury. It is recommended that hemodynamically stable pediatric patients with blunt abdominal trauma and AST levels greater than 450 IU/L and/or ALT levels greater than 250 IU/L undergo abdominal CT scan to determine the presence and extent of hepatic injury. Children with serum transaminase levels below these values are at decreased risk of liver injury.

A 40-year multinational retrospective study of 880 Swenson procedures.

This report reviews the experience of pediatric surgeons in seven cities in North American and Western Europe where the Swenson procedure was performed on 880 patients. Information on the diagnosis, treatment, complications, and long-term results was collected by reviewing the hospital records, the treating physicians' office records, and by interviewing the patients in person or by telephone. A follow-up evaluation was obtained on 814 patients. The patients' ages at the time of the resection ranged from four days to 50 years. The length of follow-up averaged 10.3 years, while the longest follow-up was 39.5 years. The overall postoperative mortality was 2.4% during the entire 40 years of the study. The postoperative mortality has decreased to 1.25% for the last 20 years. Significant factors influencing postoperative mortality included Down's syndrome, the patient's age at the time of the operation, and leak of the distal colonic anastomosis. Most of the patients followed for over 5 years have normal bowel habits, report one to three bowel movements per day, and have no soiling. No patient has urinary incontinence or impotence.

Esophageal bougienage technique for coin ingestion in children.

An analysis was performed of 46 consecutive children who received esophageal bougienage for an ingested coin lodged in the esophagus. All patients met the following clinical criteria necessary for performance of this procedure: an acutely ingested single coin, radiographically localized in the esophagus; no previous history of an esophageal disease process, surgical procedure performed or foreign body removed; and no respiratory compromise upon physical examination. All coins were successfully advanced distally into the stomach after one pass of the bougie dilator. No complications were noted during or after performance of any procedure. Esophageal bougienage is a safe and effective method used to dislodge and pass an ingested coin from the esophagus when criteria for its performance are adhered to rigidly.

Castration-sparing management of an adolescent with huge bilateral cystic teratomas of the ovaries.

In order to avoid the castrating effect of bilateral oophorectomy in a teenager with bilateral huge ovarian teratomas, a plane of dissection was developed near each ovarian hilum, and the cysts were excised in toto without spillage. Postoperatively, menstruation resumed promptly as the hormonal levels returned to normal. Benign cystic teratomas of the ovaries can be excised without the need for oophorectomy. This ovarian-sparing technique is particularly useful in cases of bilateral teratomas, where reproductive and hormonal functions should be preserved.